Provider Demographics
NPI:1093726366
Name:MELLO, TIMOTHY J (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:MELLO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-3050
Mailing Address - Country:US
Mailing Address - Phone:802-885-6373
Mailing Address - Fax:802-885-6376
Practice Address - Street 1:29 RIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-3050
Practice Address - Country:US
Practice Address - Phone:802-885-6373
Practice Address - Fax:802-885-6376
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030562363A00000X, 363AS0400X
NH0416P363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT58641OtherBLUECROSS
341729OtherMVP
228223OtherCIGNA
VTVN1017Medicaid
NH30334363Medicaid
NHAP1639Medicare ID - Type Unspecified
341729OtherMVP
P09156Medicare UPIN